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Objective: To assess the degree of postoperative satisfaction of patients with acute Achilles tendon rupture who underwent surgical reconstruction by a minimally invasive technique using Tenolig®. Methods: A retrospective observational study was conducted with 18 patients with acute Achilles tendon rupture diagnosed by a positive Thompson test who underwent surgery. Outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Foot Function Index (FFI). Furthermore, quantitative variables were descriptively treated, and patients’ age was correlated with FII and AOFAS score using Spearman’s correlation coefficient at a significance level of 5%. Results: Patients underwent surgery from one to six days after injury and were discharged one day later. Only one patient had a superficial postoperative infection. Patients’ AOFAS scores ranged from 75 to 100 points, and FFI ranged from 0 to 20%. The patient with superficial postoperative infection had an AOFAS score and a FFI of 75 points and 20%, respectively. Conclusion: Percutaneous repair of complete Achilles tendon rupture with Tenolig® resulted in high functional scores and a low rate of complications. Level of Evidence IV; Therapeutic Studies; Case Series. Descriptors: Achilles tendon; Rupture; Orthopedic procedures; Patient satisfaction. Study performed at the Hospital Santa Marcelina, São Paulo, SP, Brazil. Correspondence: Vinicius Cambaúva Menescal de Oliveira. 9 do Vale Av., Renascença, São Luís, Maranhão, Brazil, Zip Code: 65075-660. Conflicts of interest: none. Source of funding: none. Date received: August 27, 2020. Date accepted: November 30, 2020. Online: December 21, 2020 How to cite this article: Oliveira VCM, Prata SDS. Achilles tendon repair by a minimally invasive technique using Tenolig®. J Foot Ankle. 2020;14(3):269-73. Introduction Achilles tendon rupture is the third most frequent tendon injury in the human body and the most frequent in the lower limb(1). The Achilles tendon, the longest (15cm) and strongest tendon in the body, originates in the gastrocnemius and soleus muscles and is inserted in the posterior portion of the calcaneus; it is also has the highest rates of rupture. In 1990, G. T. Kuwada published a classification system of Achilles tendon rupture to guide treatment options. Type 1 injuries are partial ruptures that should be treated by immobilization with cast. Type 2 injuries consist of those with complete rupture and a tendinous gap smaller than 3cm between the stumps with the ankle at 90 degrees, and their recommended treatment is end-to-end tenodesis. Type 3 injuries, which have a tendinous gap from 3 to 6cm, may be treated with V-Y advancement, tend transfer, Bosworth turndown, or a combination of the three. Injuries measuring more than 6cm require gastrocnemius elongation, free tendon graft, synthetic graft, or a combination of these methods(2). The treatment of this problem is controversial among the professionals, since some of them advocate for conservative methods and others prefer surgery. Conservative treatment requires prolonged immobilization, does not pose risks for complications or skin infection, but has high rates of rerupture, tendon elongation, and muscle mass loss. Conversely, open surgery restores tendon continuity, but poses risk for adherences and skin complications (profound infection and tendon adherence), in addition to neurologic injury. Several percutaneous techniques have been described since 1977, such as the Tenolig® (FH Orthopaedics, Heimsbrunn, France), a device developed to maintain the tendon in contact with each other. The Tenolig® kit consists of two wires with anchors at one end and needles at the other end; two washers and two poliethylene disks for securing the distal end of the wire(3,4). Oliveira et al. Achilles tendon repair by a minimally invasive technique using Tenolig® 270 J Foot Ankle. 2020;14(3):269-73 This type of injury is often treated by the foot and ankle team of the referral service in Orthopedics and Trauma at a hospital located in the east region of the city of São Paulo, Brazil. Surgical tendon repair may be performed by the following techniques: open and minimally invasive with percutaneous approach, a simple and rapid procedure, with early return to daily activities(1,5). The standard percutaneous technique consists of: (1) union of the ruptured ends without using a large surgical approach, thus also avoiding the drainage of the local hematoma and rushing the repair; (2) avoiding damaging of the tendon’s vascular supply. This technique leads to a rapid transformation of the collagen fibers into elastic fibers, which are mechanically effective. Complications include: sural nerve injury, infection, rerupture, deep vein thrombosis, and hypertrophic scars. Thus, the procedure may not be appropriate for patients with diabetes mellitus or peripheral vascular disease(4,6). The importance of the present study relies on analyzing the outcome of the minimally invasive technique for the percutaneous repair of the tendon injury using Tenolig® and assess the degree of patients’ postoperative satisfaction, based on pain level, functionality, and ankle and hindfoot mobility. Therefore, our study will contribute for the planning of future procedures and for the management of individuals with this type of injury and have a surgical indication. The aim of this study is to assess the degree of postoperative satisfaction of patients who underwent a minimally invasive technique for repair of acute Achilles tendon rupture. Methods This study was approved by the Institutional Review Board and registered on the Plataforma Brasil database under CAAE (Ethics Evaluation Submission Certificate) number: 98291018.3.0000.0066. A retrospective observational study was conducted with 18 patients who underwent Achilles tendon repair with a percutaneous suture from September 2017 to October 2019 and were followed up by the Orthopedics and Trauma service of a hospital located in the east region of the city of São Paulo, Brazil. Exclusion criteria were patients who underwent other surgical techniques or who received conservative treatment, patients with other associated diseases, and those refused to answer the questionnaires and/or did not sign the Informed Consent Form (ICF). Initially, the researchers assessed the electronic medical records of the 18 patients who underwent the minimally invasive technique during the study period, who were contacted by phone and invited to participate in the research. Next, those who agree to participate were evaluated using the following instruments: the American Orthopaedic Foot and Ankle Society (AOFAS) scale(7), which analyzes pain, functionality, maximum walking distance in blocks, walking surfaces, gain abnormality, sagittal mobility (flexion and extension), hindfoot mobility (inversion and eversion), ankle-hindfoot stability, and alignment; and the Foot Function Index (FFI) questionnaire(8), initially developed in English and subsequently translated into Portuguese and revised, in order to assess foot functionality in patients with musculoskeletal injuries. That said, the diagnosis of Achilles tendon was clinical in all patients, consisting of a positive Thompson test for the injury and of the presence of a gap in the topographic region of the injury. The test was applied with the patient placed in the horizontal prone position with the knee flexed at 90 degrees, and the examiner then squeezes the calf muscle. In normal conditions, this procedure should result in plantar flexion of the ankle, but it is not observed in the presence of a complete Achilles tendon injury. An important sign of injury is the presence of a gap detected by physical examination. Moreover, the collected data were referred to statistical analysis, in which all variables were initially subjected to descriptive analysis. Then the analysis proceeded with the identification of minimum and maximum values and the calculation of means, standard deviations, and medians, for quantitative variables, and with the calculation of absolute and relative frequencies for qualitative variables. Correlation between scores and age was assessed using the Spearman correlation coefficient(9). The SPSS 17.0 for Windows software was used for calculations. The level of significance for the tests was set at 5%. Surgical description The patient is placed in the prone position under spinal anesthesia; asepsis and antisepsis of the affected lower limb are performed; sterile fields are placed; a sterile cushion is positioned in the anterior region of the ankle to maintain it initially at 90 degrees; a surgical pen was used to draw the proximal and distal stumps of the ruptured tendon through simple palpation; proximal entry points were demarcated 5cm above the injured region on the posteromedial and posterolateral surfaces of the tendon; distal exit points were demarcated 5cm below the injured region on the posteromedial and posterolateral surfaces of the tendon; a small incision was made on the entry site; the first Tenolig® is inserted using strong tweezers, the needle penetrates the tendon perpendicularly, and the surgeon feels the knee crossing the gap site under his/her finger; then the needle penetrates the distal stump and exits at the previously established point; the needle is pulled outwards until the anchor n is positioned at the level of the proximal entry point; the second Tenolig® is inserted in the same manner, on opposite sides; for the tightening, the pad is removed to position the ankle in a maximum equinus position, the two straps are pulled tight simultaneously, thus making sure that the anchors are properly anchored; the plastic disks are threaded on, with convex surface against the skin; washers were inserted fixed using pliers; the implant is tested after having relaxed the tension of the straps; the distal ends of the straps are cut 3cm from the washers; proxima